The Reproductive, Maternal and Neonatal Health Innovation Fund (RIF) Policy brief
June 2018
RIF (2013-2018) has been funded by the UK’s Department for International Development (DFID) and managed by Ethiopia’s Federal Ministry of Health (FMOH) with the assistance of a Technical Assistance Supplier (Pathfinder International).
The Reproductive Maternal and Neonatal Health Innovation Fund (RIF) has aimed to improve the health outcomes of women, newborns and young people in the pastoralist areas of Ethiopia. With RIF funding, FMOH has administered grants to both government and non-governmental implementing partners. They have been tasked with identifying innovative solutions to the barriers that prevent pastoralist populations (especially women and young people) from accessing reproductive, maternal and neonatal health (RMNH) services
The EDHS 2016 shows that Ethiopia has made significant gains in contraceptive prevalence rates since 2000.1 Over the period 2000-2016, modern contraceptive use by currently married Ethiopian women has increased steadily from 6% of women using modern contraceptive methods in 2000 to 35% in 2016.
However, pastoralist regions, particularly Somali and Afar, continue to lag behind with persistently low levels of contraceptive uptake over the period 2000-2016 (Figure 1)
To assess the RIF programme’s contribution to results, we have referred to HMIS data. While HMIS data is less reliable than EDHS data, it can be better aligned to RIF’s intervention timeframes, geographic coverage (pastoralist zones and woredas), and output level indicators.
Review of HMIS data by region (based on aggregation of woreda level data in pastoralist zones) points to some improvements in contraceptive acceptance rates (CAR).
For example, review of HMIS data for Afar Region shows a positive trend in CAR (new (N) and return (R) visits) with some acceleration in the first two years of the RIF programme (EFY 2006-2008; Gregorian calendar, 2014-2017)2 (Figure 2).
A strong upward trend in CAR has also been found in Somali Region over the programme period EFY 2006- 2009, although trends were flatter for the pastoralist zones of Oromia and SNNPR over this timeframe.
Despite some evidence of progress, and a possible contribution of the RIF programme to improved family planning uptake, absolute numbers for use of modern contraceptives remain relatively low, suggesting that there are still considerable challenges to meeting the unmet need for family planning in pastoralist areas.
Trends in RMNH indicators for Afar Region, EFY 2000-2009 showing acceleration of CAR over the period EFY 2006-2008 (2014-2016)
Source: regional HMIS data
The RIF portfolio included grants to regional universities for operational research studies. Several of these studies examined issues relating to family planning in pastoralist areas This research established that in Afar and Somali Regions there tends to be strong resistance to modern family planning methods, mostly for religious reasons, and a widespread belief that a large family is a blessing from God. If a woman uses a modern contraceptive method secretly, she risks a beating from her husband. There appeared to be slightly more openness to the use of modern contraceptive methods in the Christian areas of Oromia and SNNP regions. In addition, having many children is seen as ‘protective’ against the risk of child death, and useful for sharing the work burden in future. There are also concerns about quality of health care, side-effects and long-term consequences for fertility.
In Afar, Somali and Oromia Regions, pre-marital use of contraception was a taboo subject – again for religious reasons. More generally, family planning was only considered to be an option for women in stricken circumstances, or women with large families. When used, injectables (especially of the kind giving three-months protection) tended to be the preferred method because they could be used discreetly. Information about family planning and reproductive health was generally obtained directly from health care providers or through community meetings and campaigns.
Mass media campaigns were reported to be of limited value because few pastoralists had access to radio or television.
While the RIF studies confirmed the enduring nature of traditional norms and values on family planning, some (e.g. those conducted in Oromia and Somali Regions) pointed to significant supply-side factors, such as expired family planning drugs and negative attitudes among service providers themselves. A study conducted by Jijiga University in Somali Region found that even senior health professionals are opposed to family planning. 3 As the following quotes from the study show, health professionals do not use family planning themselves, so do not expect clients to do so.
“… why a person would use medications intended for controlling the number of children Why would a health professional believe everything that is told and limit the population of his people I don’t use family planning and I am not willing to provide” (34-year-old doctor)
“You asked me about my staff, let us be frank, even at the family department of the RHB staff do not use family planning. Even the RHB head do not use or believe in using modern family planning methods. Start from there.” (Health Centre Head)
RIF addressed unmet need for family planning in the pastoralist zones using a reproductive health ‘continuum of care’ approach consistent with WHO recommendations4 and situating family planning within an integrated package of services that cover pre-pregnancy, pregnancy and childbirth. To support this approach, RIF implementing partners used a combination of interventions that addressed four thematic areas: service uptake; community attitudes; women and girl’s empowerment; and service provider responsiveness and accountability.
Towards the end of the programme, the RIF evaluators triangulated information from various sources to identify the successful interventions based on three main criteria: likely contribution to results; stakeholder and beneficiary endorsement; and potential for scalability/sustainability. Early closure of the programme meant that it was not possible to measure definitive final results; however, the evaluators were able to identify several ‘promising practices’ that could contribute to improved attitudes and use of family planning over the longer term. The table in the next page shows four examples of strong promising practices addressing demand and supply side issues
Promising practice
Solarpowered minimedia kits
Description
Use of portable, solar-powered screens and media centres to bring information on FP and other RMNH themes to hard-toreach areas.
Factors in success
• Key influencers (local officials, community leaders and service providers) involved in design and dissemination of content.
• Highly localised RMNH information and messages.
• Follow up with facilitated community conversations.
Working with local religious and community leaders
Engaging opinion leaders and ‘gatekeepers’ through targeted education, peer networking and dialogue. Includes specialist theological discussion; presentation at the Pastoralist Forum and adaptation of traditional (e.g. Gadaa) ceremonies.
• Most effective when: a) includes peer support network and highly respected leaders; b) when involves personal testimony and living by example.
• Respected TBAs can be effective in engaging ‘gatekeepers’.
Solar Mobile RMNH Centres
Solar-Powered Mobile Health Centres extend access to RMNH services (including family planning) to the most geographically hard-to-reach populations. Vehicles are fitted with equipment providing comprehensive, energy-efficient services. Tracking software allows the vehicle to follow pastoralist movements.
• Fully-staffed vehicles are best managed from the Zonal Hospital so they can be deployed across woreda boundaries. They can then follow pastoralist migrations and maximise geographical coverage.
Social accountability initiatives with service providers
A package of interventions including training for facility staff and boards, regular meetings between providers and community representatives and a joint plan to address problems identified.
• Requires skills, supervision and management support from regional and woreda health bureaus.
• Most effective when builds on early success.
• Must be practical and acknowledge that some structural problems cannot be solved locally.
Family planning requires a ‘systems’ approach that simultaneously addresses demand and supply side issues. Aggregated evaluation evidence from the RIF programme5 suggests that interventions are likely to be most effective in pastoralist areas if they are consistent with the RMNH continuum of care. Several policy recommendations have emerged from RIF operational research and implementation experience:
• Ensure new initiatives and IEC efforts are informed by evidence from local operational research, using behaviour-change theory and evidence. Consider that information and knowledge do not necessarily translate into practice. Build new initiatives from mutually-reinforcing elements that operate at each structural level (i.e. at individual, community and higher institutional and social levels). For example, combine health education work with facilitated community conversations, use of new media and technology, support by respected champions, and a supportive policy and training environment.
• Identify and engage local gatekeepers and influencers. In the pastoralist areas these are likely to include clan and religious leaders. Engage them in the development, translation and dissemination of appropriate messages. If possible, promote living by example and personal testimonies. Link community leaders to supportive peer networks where they have access to accurate information and their efforts gain recognition. Work with community leaders to engage other key influencers, such as Traditional Birth Attendants and male partners, and ensure any misconceptions about family planning are actively addressed. Make provision for all these activities to be appropriately resourced, regularly monitored and reviewed.
• Ensure that an appropriate mix of convenient family planning methods are reliably available at all health facilities in pastoralist areas, appropriately stored in the harsh climatic conditions of these areas. Where possible, include family planning services in mobile health services. Ensure that service providers are fully trained to provide accurate and impartial information on family planning (as part of reproductive health and rights) and they are fully confident in the clinical management of all family planning methods in the government’s essential health package.
• Address attitudes to family planning among service providers. Ensure values clarification work commences with basic training and forms part of ongoing professional development across all health cadres at each level of the health system. Strengthen performance management and supportive supervision systems in pastoralist areas to ensure that all health professionals comply with the required standards regarding all aspects of the RMNH continuum of care.
• Continue to support child survival interventions. Compare child mortality rates in pastoralist areas with other areas, and stress the importance of enhancing child survival as a prerequisite for family planning.
1. Source: EDHS 2016, p. 105. Note EDHS results for SNNPR and Oromia have not been disaggregated to show results for pastoralist zones.
2. The dip in EFY 2009 is difficult to explain but could be associated with disrupted programme disbursements during the period Round 2 as implementing partners were recruited and brought on stream.
3. Hashi A. et al. (undated). Barriers of modern Family Planning utilization: A perspective from health care providers in Ethiopia-Somali Region
4. WHO (2010) Packages of Interventions for Family Planning, Safe Abortion care, Maternal, Newborn and Child Health.
5. Mott MacDonald. 2016. Monitoring & Evaluation of the Reproductive, Maternal & Neonatal Health Innovation Fund. Baseline Supplement: Qualitative Findings (evaluation report submitted to DFID Ethiopia, 16 September 2016).
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